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Increasing Adherence to Annual Screening - Data Review


This article provides a step-by-step review of the Lung Cancer Screening Registry (LCSR) reports you can use to determine if your facility can increase adherance to annual screening for patients with a Lung-RADS® 1 or 2 recommendation enrolled in your lung cancer screening program. If a gap in performance is identified, pursuing a LCSR Plan-Do-Study-Act (PDSA) Performance Improvement project could help your facility get on the road to improvement. Visit LCSR Performance Improvement Overview for details about conducting a project. 

Note: If you are not familiar with logging into NRDR and the LCSR reports, or need a refresher, review the PDSA Walkthrough article.

Reviewing the Reports

Get started by reading the LCSR Facility Comparisons Report article to obtain information about how to access the report and an overview of the various report tabs. Each report tab contains help features that provide more information about the report’s functionality.  

Note: Please keep in mind your facility’s data submission practices when reviewing the reports and how these may affect report results.

The following is a suggested stepwise progression for reviewing the LCSR Facility Comparison Report tabs to help pinpoint areas that could benefit from a performance improvement initiative.

  1. Review the LCSR Facility Peer Comparison Report: View aggregate data about how your facility (or how multiple facilities within the same corporate account) compares to peer groups and to all registry participants.

    1. View your facility’s rankings for the three Plan-Do-Study-Act (PDSA) measures to determine if there are measures for which your facility falls below peer performance suggesting an opportunity for improvement.

    2. Even if your facility ranks in the highest quartile, consider if there is still significant room for improvement.

  2. Review the LCSR Facility Comparison Report (for corporate accounts with more than one facility): Compare performance across all facilities within a corporate account.

    1. Identify which facilities could most benefit from participating in a performance improvement initiative or how your facility compares with others in your corporate account.

  3. Review the LCSR Annual Trends Report: Observe performance over time to understand variations and determine factors within your program that may have led to changes in performance.

  4. Review the LCSR Adherence to Annual Screening Report: View your performance regarding percentage of patients who return for follow-up screening within 11 to 15 months after their previous Lung-RADS® 1 or 2 screening exam.  

  5. Review the PI Reports: Focus on the parameters for your PDSA cycle.

    1. Decide if an improvement effort will include one or multiple facilities.

    2. Determine an appropriate date range for a good representation of your data.

    3. Evaluate the data to see if there is an improvement trend or if some adjustment needs to be made to the intervention.

Recording LCSR Report Data for Your PI Project  

The PDSA Worksheet documents data from the LCSR reports in the Plan and Study sections as described below.

  1. Investigate performance data available in the PI Analysis Report:

    1. Select a measure using the Chart Measure filter to view performance trends of interest.

    2. Use the Show Data By filter to select whether to view the aggregated performance data by facility or corporate account.

    3. Use the Comparison Statistics filter to view your performance as compared to the performance of all registry facilities (using data from the previous year) indicated by the dotted red line for the median, 75%, or 95% performance results.

    4. Select the Show Detail filter to see all exams contributing to the trend chart. Click a data point in the trend chart to filter the exams table.

An example of the PI Analysis Report below shows the adherence rate for multiple facilities within a corporate account. The “opportunity” bubbles show the screening volume difference between the facilities and suggest that focusing efforts on the facility represented in green may be a good strategy given the higher volume of patients screened at this facility.

Select the option Yes in the Show Exams dropdown filter to display an exam detail table that presents information about patients’ adherence history for the date range selected. Hover over a dot in the graph to display the performance summary for a specific month.  

The example below shows results from January through July 2022 for a facility with a 34.6 % adherence rate as compared to the registry median of 26.4 % for the same period in 2021.

  1. Calculate pre- and post-PI metrics for your PDSA project using the PI Assessment Report. The report plots adherence over time along with displaying the upper and lower control limits defined as +/- three standard deviations from the mean.

    1. Use the Baseline date selector to display your project’s baseline period. After your intervention, use the Post Intervention date selector to monitor its effect on performance.  

    2. Use the Show filter to view performance results by month or by week. Select the Baseline vs. Post Intervention option to view a side-by-side comparison of your project’s results.

    3. View a control limits video to learn more about their use for understanding performance improvement.

Note: The Corporate Account and Facility filers operate independently of the rest of the report. Consequently, selections from other Facility Peer Comparison reports do not carry over to the performance improvement reports.

The PI Assessment Report below displays an example of three months of baseline data followed by a three-month timeframe for implementing an intervention. Three months post intervention, the data suggest modest improvement has been achieved and the facility should continue to monitor if the upward trend continues.

Selecting Baseline vs. Post Intervention in the Show filter displays the graph below demonstrating modest improvement.

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